Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Boca Ciega Center during CMS and state inspections, most recent first.
Two residents were involved in an unwitnessed altercation after a severely cognitively impaired, wheelchair-propelled resident with dementia and aphasia, known by staff to wander and enter other residents’ rooms, went into another cognitively intact resident’s room and put on that resident’s shoes. Video showed the wandering resident entering the room and later exiting with visible facial bleeding and mismatched shoes, while the other resident left the room without visible blood. Progress notes and skin assessments documented multiple new facial injuries and emotional distress in the injured resident. Staff interviews confirmed a longstanding pattern of the injured resident going into other rooms and being redirected without consistent documentation, while facility leadership reported they were unaware of this behavior despite an existing behavior care plan and an abuse prevention policy requiring identification of residents whose behaviors might lead to conflict. This lack of effective supervision and communication led to the resident-to-resident altercation and resulting injuries.
Surveyors identified that the facility did not maintain required documentation for generator testing and maintenance, including missing records for monthly load tests, annual load bank and battery tests, weekly battery voltage checks, annual preventative maintenance, and main breaker testing, as required by NFPA standards.
Two residents in a LTC facility did not receive timely incontinence care, leading to discomfort. Interviews revealed staffing challenges, with CNAs managing high resident loads and being pulled for other duties, causing delays in care. Documentation showed gaps in care provision, and the facility lacked specific policies for ADL and incontinence care.
The facility failed to maintain a clean and sanitary kitchen environment, with observations of dirty trash cans, food trays piled up, dirt and food particles on the walk-in refrigerator floor, and a dirty stove with missing knob covers. Interviews with the CDM and Nursing Home Administrator confirmed awareness of the issues, which violated the facility's cleaning and sanitation policy.
The facility failed to ensure a safe, clean, and homelike environment for residents, with observations of broken furniture, structural damage, and unsanitary bathroom conditions. Maintenance and housekeeping staff confirmed the need for extensive repairs and cleaning.
The facility failed to properly update and review care plans for several residents, leading to inaccuracies in care planning and documentation. This included not reflecting discontinued medications, redundant interventions, and missing care plans for significant physical limitations.
The facility failed to provide appropriate restorative therapy for two residents, leading to deficiencies in their range of motion and mobility. One resident with Multiple Sclerosis was observed without necessary splints, and staff were unaware of their responsibilities. Another resident with encephalopathy had significant limitations in her upper extremities, with no active care plan addressing her ROM needs. The lack of coordination and communication among staff contributed to these deficiencies.
The facility failed to ensure proper infection control during medication administration, PPE usage, and resident hand hygiene. Staff were observed not offering hand hygiene to residents before meals, mishandling PPE, and improperly administering medications, contrary to facility policies.
The facility failed to ensure a resident's call light was consistently within reach, despite the resident's medical conditions requiring easy access. Staff confirmed the call light should be accessible, but it was repeatedly found out of reach, and the facility lacked a policy for call lights.
The facility failed to provide adequate ADL assistance to two dependent residents, resulting in unmet personal hygiene needs. One resident, who is cognitively intact and dependent on staff for personal hygiene, was observed with long, dirty fingernails and thick facial hair despite requesting assistance. Another resident with reduced mobility was observed with knotted hair and overgrown fingernails, and was not engaged in any activities. The facility lacked a policy for ADL care, leading to inconsistent care and documentation.
The facility failed to provide necessary activities for two dependent residents according to their care plans. Observations showed the residents were often in bed, disheveled, and not engaged in activities. Staff interviews revealed that the Activities Director was too busy to conduct activities for dependent residents, and some CNAs did not document refusals or encourage participation.
A resident with end-stage renal disease requiring dialysis did not receive timely post-dialysis vital signs checks and AV fistula assessments as per physician orders. The facility's dialysis communication binder showed inconsistent documentation and lack of timely communication from the dialysis center. The resident reported excessive bleeding from the AV fistula site, but the nursing staff did not check his vital signs or assess the site upon his return.
The facility failed to obtain blood pressures for a resident as required by the physician's order for Hydralazine, a vasodilator. The resident had essential hypertension and a history of cerebral infarction. Blood pressures were only taken once a week instead of every 8 hours, making it impossible to determine the necessity for administering Hydralazine. Additionally, blood pressures were not taken prior to administering other hypertension medications, contrary to the physician's orders.
The facility failed to ensure safe and secure medication storage, did not discard expired medications, and did not label medications with shortened shelf lives with open dates. Observations revealed undated and expired medications, improper storage, and discrepancies in medication administration records.
The facility failed to assess and obtain physician orders for the wounds of two residents, leading to deficiencies in wound care management. One resident had a dressing on a left below the knee amputation that was not changed for several days without a physician order, and another resident had gaps in documentation and physician orders for wound care. The facility's wound care protocol was not followed, resulting in inadequate wound care management.
Failure to Supervise Wandering Resident Leads to Resident-to-Resident Altercation and Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent resident-to-resident altercation, resulting in injury to a severely cognitively impaired resident. One resident (Resident #5) had a diagnosis that included unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, encephalopathy, difficulty in walking, and a cognitive communication deficit, with a BIMS score of 0 indicating severe cognitive impairment. This resident was able to self-propel in a wheelchair, wore a wanderguard, and was known by staff to wander, enter other residents’ rooms, and rummage through their belongings. Another resident (Resident #6), cognitively intact with a BIMS score of 14, had multiple medical diagnoses including chronic pain syndrome, neuromuscular dysfunction of bladder, idiopathic progressive neuropathy, generalized anxiety disorder, bipolar disorder, type 2 diabetes, and atherosclerotic heart disease. On the day of the incident, video footage showed Resident #5 in his wheelchair near the exit doors outside Resident #6’s room, touching the wall, and then self-propelling into Resident #6’s room. Approximately ten minutes later, Resident #6 returned to his room in a motorized wheelchair and entered, with the door closing to leave about a one-foot opening. A short time later, Resident #5 exited the room in his wheelchair with a visible stream of blood from his eye down his cheek to his mouth and wearing two different shoes. Staff B, an LPN, was then seen approaching the area and entering a room across from Resident #6’s room before leaving the camera’s view toward the nurses’ station, and Resident #6 later exited his room without visible blood on his person. Progress notes documented that staff observed an altercation between two residents on the hall after one resident was found in another resident’s room touching property and putting on the other resident’s shoes. Verbal escalation occurred, followed by punches being thrown by both residents. Resident #5 was later documented as crying and stating he was “punching and punching,” and was found with injuries including a left eyebrow cut, a left temple hematoma, and an abrasion below the left temple. Staff interviews confirmed that Resident #5 frequently went into other residents’ rooms, did not know where his own room was, and required redirection, although CNAs reported they did not document these room entries. The MDS coordinator confirmed a behavior care plan for wandering into other residents’ rooms had been initiated, and the care plan included interventions such as documenting behaviors, diverting attention, and removing the resident from situations as needed. However, the DON and Nursing Home Administrator stated they were unaware of Resident #5’s behavior of entering other residents’ rooms until after this event, despite the facility’s Abuse Prevention Program policy stating that leadership will identify residents with needs or behaviors that might lead to conflict or abuse/neglect. Additional observations and interviews further illustrated the ongoing wandering behavior and lack of effective supervision. On the survey date, Resident #5 was observed in the dining room with a speech therapist, with visible bruising on the left outer eye area, and the speech therapist described him as oriented only to self, not knowing where his room was, and spending much of the day looking for it. During an interview with an LPN, Resident #5 was again observed at the end of the hall next to the exit doors outside Resident #6’s room, requiring the nurse to run down the hall and redirect him back toward the nurses’ station. CNAs reported that Resident #5 had been going into other residents’ rooms since admission and that they redirected him when observed, but did not document these behaviors. These documented patterns of wandering into other residents’ rooms, combined with the facility leadership’s lack of awareness of the behavior and the unwitnessed altercation that resulted in injury, demonstrate the facility’s failure to ensure adequate supervision and to prevent resident-to-resident altercation as required by its own policies and regulatory standards. The facility’s Abuse Prevention Program policy, last revised in 03/2022, stated that leadership would identify situations in which abuse, neglect, mistreatment, exploitation, or misappropriation may be more likely to occur, including residents with needs or behaviors that might lead to conflict or abuse/neglect. Despite this, the DON and NHA reported they were not aware of Resident #5’s behavior of entering other residents’ rooms, even though multiple staff members, including CNAs and the MDS coordinator, acknowledged this behavior and a behavior care plan had been initiated. The lack of consistent documentation and communication about Resident #5’s wandering and room-entry behavior, combined with the absence of effective supervision to prevent him from entering Resident #6’s room and the subsequent altercation, led directly to the resident-to-resident incident and injuries that formed the basis of the cited deficiency.
Failure to Maintain Generator Testing and Maintenance Documentation
Penalty
Summary
The facility failed to maintain required documentation of generator testing and maintenance in accordance with NFPA 101, NFPA 99, and NFPA 110 standards. During a record review with the Administrator and Maintenance Director, surveyors found that there was no evidence provided for several critical generator tests and maintenance activities. Specifically, documentation was missing for the monthly 30% load test, the annual 1.5-hour load bank test, battery conductance tests, weekly battery voltage tests, annual preventative maintenance, and the annual main breaker test. The Maintenance Director confirmed that the only documentation available was the most recent report from their generator company, which did not include the required records. These findings were discussed with both the Maintenance Director and the Administrator during the exit conference. The lack of documentation for these essential electrical system tests and maintenance activities constitutes a deficiency, as it does not meet the requirements set forth by the referenced NFPA codes. No information about residents or their conditions was included in the report.
Inadequate Incontinence Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to discomfort and potential health risks. Resident #2 reported that his incontinence needs had not been addressed since the previous night, and Resident #1 stated that her last incontinence care was at 3:30 a.m., leaving her wet and uncomfortable. Both residents expressed dissatisfaction with the care they received, highlighting a delay in addressing their needs. Interviews with staff revealed significant staffing challenges that contributed to the deficiency. Staff E, a CNA, was unable to specify the number of residents she was responsible for, indicating a lack of clarity in assignments. Other CNAs reported high resident loads, with some responsible for up to fourteen residents, many of whom required total care. The CNAs expressed that the workload was overwhelming, and the removal of staff to assist in the main dining area further exacerbated the situation, delaying care for residents. The facility's documentation showed gaps in the provision of care, with Resident #1 receiving toileting care only once during the night and no further entries documented. Similarly, Resident #2's care records indicated long intervals between incontinence care. Despite the facility's stated policy of checking residents every two hours, the evidence suggested that this standard was not consistently met. The lack of specific policies for ADL and incontinence care further contributed to the inconsistency in care delivery.
Failure to Maintain a Clean and Sanitary Kitchen
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen environment, as observed during multiple inspections. On an initial tour of the kitchen, a dirty trash can was found next to the hand washing station, and food trays were piled up on the kitchen sink during meal preparation. Additionally, dirt and food particles were observed on the walk-in refrigerator floor. During a follow-up visit, the kitchen stove was found dirty with grease and missing stove knob covers. An open garbage can was observed next to cooked food on the stove, and the kitchen floor was repeatedly noted to be dirty throughout the survey period. Interviews with the Certified Dietary Manager (CDM) and the Nursing Home Administrator revealed acknowledgment of the cleanliness issues. The CDM admitted that certain areas in the kitchen needed cleaning and that the walk-in refrigerator floor was particularly difficult to clean. The Nursing Home Administrator confirmed that she had discussed the cleanliness issues with the CDM multiple times and found the current state of the kitchen unacceptable. The facility's policy on cleaning and sanitation, effective since September 2012, mandates a clean and sanitary environment, including covered trash cans and sanitized kitchen equipment, which was not adhered to in this instance.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for resident rooms and bathrooms over a four-day observation period. Specific deficiencies included broken furniture, such as lopsided drawers and missing doorknobs, as well as structural damage like deep gouges in the drywall and cracked sinks with visible brownish/black substances. Additionally, the facility's bathrooms were found to be in poor condition, with missing tiles, discolored grout, and black substances on shower curtains and caulking. Rusty safety handles and reports of palmetto bugs/roaches further highlighted the unsanitary conditions. These observations were confirmed by the Maintenance Director and the Nursing Home Administrator, who acknowledged the need for repairs and cleaning. The facility's policy on maintaining a safe, clean, and comfortable environment was not adhered to, as evidenced by the numerous deficiencies observed. The Maintenance Director and Environmental District Manager confirmed the unacceptable conditions, noting that the entire building needed auditing and repairs. The Housekeeping Manager also acknowledged the persistent issues with cleanliness and maintenance, such as the recurring rust on safety handles. Photographic evidence was obtained to document these deficiencies, further substantiating the need for immediate corrective action.
Care Plan Deficiencies
Penalty
Summary
The facility failed to revise and review the care plan for Resident #60 with the appropriate staff and professionals. Despite the resident having an intact cognition with a BIMS score of 13 out of 15, there was no evidence of participation in care planning meetings. The care plan goals were revised, but there were no progress notes indicating a care plan meeting had been held. Staff interviews confirmed the lack of documentation and awareness regarding the resident's care plan meetings and invitations, indicating a failure in the care planning process for this resident. Resident #55's care plan was not updated to reflect the discontinuation of psychotropic medications. The resident's care plan still indicated the use of antidepressants, despite the last psychotropic medication, Trazodone, being discontinued in October 2023. Staff interviews confirmed that the care plan should have been resolved when the medication was discontinued, but it remained unchanged, leading to inaccurate care planning for the resident. Resident #1's care plan contained redundant interventions regarding toileting, and the fall care plan was not appropriately updated after a fall incident. The resident was observed on the floor, and staff confirmed that the care plan should have been reviewed and updated with appropriate interventions. Similarly, Resident #47's care plan was not updated to reflect current dietary and catheter orders, leading to potential miscommunication among care staff. Resident #85's care plan lacked an ADL care plan despite the resident's significant physical limitations, as confirmed by staff interviews. The facility's policy emphasized the importance of updating care plans, but this was not adhered to in these cases, resulting in deficiencies in care planning and documentation.
Failure to Provide Appropriate Restorative Therapy
Penalty
Summary
The facility failed to provide appropriate restorative therapy for two residents, leading to deficiencies in their range of motion (ROM) and mobility. Resident #30, diagnosed with Multiple Sclerosis (MS) and other conditions, was observed without the necessary splints that were part of his care plan. Interviews with staff revealed confusion and lack of awareness about the restorative therapy program, with some staff members unaware of their responsibilities or the location of necessary equipment. The Program Manager and other staff members confirmed that the restorative therapy program, known as the Functional Maintenance program, was not being properly implemented or monitored, resulting in Resident #30 not receiving the required care to maintain his ROM. Resident #85, with diagnoses including encephalopathy and abnormalities of gait and mobility, was observed with significant limitations in her upper extremities, unable to open her fingers or extend her arms. The resident's care plan for Activities of Daily Living (ADL) had been resolved, and there was no active plan addressing her ROM needs. Interviews with staff indicated a lack of clarity on who was responsible for providing ROM exercises, with some staff members noticing the resident's decline but not taking appropriate action. The Director of Rehabilitation confirmed the need for an evaluation and planned to request an order from the physician. The facility's failure to properly implement and monitor the restorative therapy program for these residents resulted in a decline in their ROM and mobility. The lack of coordination and communication among staff, as well as the absence of clear ownership of the restorative therapy program, contributed to these deficiencies. The Assistant Director of Nursing acknowledged the issue and indicated that it would be addressed, but at the time of the survey, the deficiencies remained uncorrected.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration, personal protective equipment (PPE) usage, and resident hand hygiene. Observations revealed that residents were not offered hand hygiene prior to meals, and staff members were seen delivering meal trays without encouraging or assisting residents with hand hygiene. Additionally, an Activities Director was observed using a wet paper towel to clean a resident's hands before assisting with feeding, which is not an appropriate method for hand hygiene. During incontinence care for a resident on Enhanced Precaution Isolation, a CNA was observed rummaging through the resident's closet and leaving the room with the same PPE used during care, contaminating multiple surfaces including a locked linen closet keypad. Another CNA appropriately removed and donned new PPE before continuing care. This incident was reported to the Unit Manager, who acknowledged the breach in protocol and cleaned the contaminated keypad. Medication administration practices were also found to be deficient. An RN was observed handling medication with bare hands and inconsistently using alcohol-based hand rub between tasks. Another RN was seen dropping a pill onto a medication cart and placing it back into a medicine cup, as well as attempting to administer multiple pills at once, resulting in dropped pills being picked up with bare hands and given to the resident. These actions were contrary to the facility's policy on medication administration and hand hygiene, which emphasizes the use of gloves and proper handwashing techniques to prevent infection spread.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident #85 by not ensuring the call light was within the resident's reach. On multiple occasions, the call light was observed to be out of reach, either around the bed rail or underneath the resident's shoulder. Despite the resident's inability to reach the call light, staff members had to be reminded to place it within reach, indicating a recurring issue. Interviews with staff confirmed that the call light should always be within the resident's reach, yet this was not consistently maintained for Resident #85. The resident expressed that this issue happens frequently, highlighting a persistent problem in ensuring accessibility to the call light. Resident #85 was readmitted to the facility from an acute care hospital with medical diagnoses including encephalopathy, abnormalities of gait and mobility, lack of coordination, reduced mobility, and muscle wasting and atrophy. Despite these conditions, which necessitate easy access to the call light for assistance, the facility did not have a policy and procedure for call lights. The Director of Nursing and the Nursing Home Administrator both acknowledged that residents should be able to access the call light when needed, yet the deficiency persisted.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate ADL assistance to two dependent residents, resulting in unmet personal hygiene needs. Resident #81, who is cognitively intact and dependent on staff for personal hygiene due to paraplegia, was observed with long, dirty fingernails and thick facial hair. Despite requesting assistance multiple times, the resident's needs were not met, as confirmed by staff interviews. The CNA responsible for Resident #81 admitted to being too busy to provide the requested care, and the RN and DON confirmed that staff are expected to report and document any issues with completing ADL tasks, which was not done in this case. Resident #13, who has reduced mobility and requires substantial assistance with personal care, was observed multiple times with knotted hair and overgrown fingernails. The resident was also noted to be disheveled and not engaged in any activities. Interviews with CNAs revealed that while some staff attempted to provide care, others did not document refusals or encourage the resident to participate in ADL care. The DON confirmed that the resident's care plan did not account for refusals of care, and there was a lack of documentation and follow-up on the resident's ADL needs. The facility did not have a policy for ADL care, which contributed to the inconsistency in providing and documenting necessary personal hygiene assistance. The lack of a structured approach and clear documentation led to the neglect of essential ADL care for these residents, highlighting a significant deficiency in the facility's care practices.
Failure to Provide Activities for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with activities according to their care plans. Resident #68 was observed multiple times over several days lying in bed, dressed in a nightgown, with her call light out of reach and not engaged in any activities. The resident's care plan indicated that she required staff assistance with activities due to cognitive deficits, but the Activities Director admitted that she was too busy to conduct activities for dependent residents on the 100 hall that week. The Director of Nursing confirmed that residents should have activities according to their care plans, but this was not being met for Resident #68. Resident #13 was also observed multiple times over several days lying in bed, disheveled in appearance, and not engaged in any activities. The resident's care plan indicated that she was fully dependent and required substantial assistance with personal care and activities. Staff interviews revealed that while some CNAs attempted to provide care and activities, others did not document refusals or encourage the resident to participate in activities. The Activities Director stated that she was responsible for activities for the entire resident population but had been too busy to visit dependent residents recently. The facility did not provide their activities policy when requested. The Director of Nursing and the Activities Director both acknowledged that the current system was not meeting the needs of dependent residents, as the Activities Director was unable to conduct one-on-one activities due to being overburdened with other tasks. This led to a failure in providing necessary activities for Resident #68 and Resident #13, as outlined in their care plans.
Failure to Provide Timely Post-Dialysis Assessment and Vital Signs Monitoring
Penalty
Summary
The facility failed to provide timely assessment and vital signs monitoring for a resident who required dialysis care. Resident #53, who has a primary diagnosis of hemiplegia and hemiparesis following cerebral infarction and secondary diagnoses including end-stage renal disease requiring dialysis, did not receive post-dialysis vital signs checks and AV fistula assessments as per physician orders. The review of the resident's dialysis communication binder revealed inconsistent documentation and lack of timely communication from the dialysis center. On multiple occasions, the post-dialysis reports and vital signs were either missing or not documented promptly. On one specific instance, Resident #53 returned from dialysis and reported excessive bleeding from the AV fistula site, which required prolonged direct pressure to stop. Despite this, the nursing staff did not check the resident's vital signs or assess the AV fistula site upon his return. The resident expressed that the nursing staff never checked on his condition post-dialysis. The facility's policy on dialysis management, which includes guidelines for post-dialysis assessment and communication, was not followed, leading to a deficiency in the care provided to the resident.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to obtain blood pressures for one resident (#60) as required by the physician's order for the vasodilator Hydralazine. The resident had a diagnosis of essential hypertension and a history of cerebral infarction. The physician's order specified that Hydralazine should be administered every 8 hours as needed for systolic blood pressure greater than 160. However, the Medication Administration Records (MAR) for March and April revealed that blood pressures were only taken once a week, on Sundays, rather than every 8 hours as required. This failure to monitor blood pressure every 8 hours meant that the necessity for administering Hydralazine could not be accurately determined. Additionally, blood pressures were not taken prior to administering other hypertension medications, Hydrochlorothiazide and Metoprolol, as per the physician's orders. The care plan for the resident included interventions such as taking vital signs and administering medications as ordered, but these were not followed correctly. An interview with a Registered Nurse/Unit Manager confirmed that blood pressures should have been taken every 8 hours for the PRN Hydralazine order. The facility's policy on physician orders emphasized the importance of confirming the accuracy of orders and reviewing them daily, but there was no specific policy related to nursing documentation. The Hydralazine order was eventually discontinued on 5/1/24 at 4:01 p.m.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner, and did not discard medications after their manufacturer expiration date or label medications with shortened shelf lives with open dates. During an observation, a resident was found with a bottle of eye drops and nasal spray on their bedside table, neither of which were documented in the resident's physician orders. Another resident had a jar of Silver Sulfadiazine cream on their bedside dresser, which was labeled as prescription-only, but the resident could not confirm if they applied the cream themselves. The medication administration records showed discrepancies in the orders and application of the cream. Further observations of the medication carts revealed multiple issues, including undated and expired medications, medications stored improperly, and a lack of proper labeling. For instance, undated Latanoprost eye drops, insulin pens, and vials were found without open dates, and some insulin vials were past their discard dates. Additionally, medications were stored alongside disinfecting wipes, and a bottle of liquid protein was found undated. These findings were confirmed by the staff present during the observations.
Failure to Assess and Obtain Physician Orders for Wounds
Penalty
Summary
The facility failed to assess and obtain physician orders for the wounds of two residents, leading to deficiencies in wound care management. Resident #60 was observed with a dressing on a left below the knee amputation (LBKA) that had not been changed for several days. The dressing was dated 4/28, but no physician order or wound evaluation was found in the resident's records. Staff confirmed that there should have been a change in condition assessment and a physician order for the dressing, but these were not completed. The resident's care plan indicated a risk for developing wounds, but the necessary interventions were not followed. Resident #45 was observed with no open areas on the lower extremities, but staff reported that the area heals and reoccurs, and they were just applying cream. The resident's records showed a history of skin impairments and cellulitis, but there were gaps in documentation and physician orders for wound care. A dressing applied on 1/27 was not documented or ordered, and it remained in place for seven days without proper assessment. The facility's wound care protocol was not followed, and the incident was not substantiated because the wound had not worsened. However, the lack of proper documentation and physician orders indicated a failure in wound care management. The facility's policy on wound prevention and treatment emphasized the importance of documenting wound characteristics and providing necessary treatment to promote healing and prevent infection. However, the facility failed to adhere to this policy for both residents. The lack of proper assessment, documentation, and physician orders for wound care led to deficiencies in the quality of care provided to the residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gulfport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs At Boca Ciega Bay | 0.5 mi | ★★★★★ | 5 | 4 |
| Egret Cove Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Marion And Bernard L Samson Nursing Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Gulfport Nursing Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Aviata At The Sea - Pasadena | 1.5 mi | ★★★★★ | 0 | 0 |
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